Chiropractors, as with other primary healthcare clinicians, are often
faced with a child whom they suspect may have symptoms of autism, often previously
undiagnosed. As such, it is important that there is familiarity with the symptoms,
primary of which are difficulties in communicating or relating to other people.
Although there is no known cause for autism, various potential aetiologies are under
investigation. A number of abnormalities are found in multiple systems and functions
in the autistic individual who presents a number of management challenges.

Some researchers have discovered a laterality of the atlas in children with autism
and there are various suggestions as to why removing upper cervical dysfunction may
have a positive effect on the symptoms of autism. This paper offers a systematic
review of the condition with emphasis on the elements pertinent to the manual
therapist.

Autism is a life-long developmental disability, which, in the United Kingdom, affects approximately 90 people in every 10,000. Put into clinical perspective, this means that the average general practitioner (GP) will have 18 people with autism on their list.1

Individuals with autism are affected in different ways, but all seem to suffer from a triad of impairments: difficulty in interacting with others, impairments in social communication and difficulty thinking imaginatively. An absence of play is often one of the first obvious signs of autism.

The cause of autism is unknown; there are no universally accepted explanations. Current research favours a genetic component,2 and 3 although other factors are also implicated, including environmental triggers and imbalances in neurochemistry.4

There is no medication that can ‘cure’ autism. When medication is used, it is to treat a particular symptom of the syndrome.5 Specialist education often dramatically improves the quality of life for sufferers and their families.1

Many chiropractors and other manipulative therapists report good symptomatic improvements following treatment.6 However, there is little literature available to support these claims.

Autism affects the way a person communicates and relates to people around them, particularly with respect to understanding other people's emotional expression. Learning difficulties may further compound the difficulties that they face.1

The clinical picture of autism varies between individuals and it is for this reason that the concept of a spectrum of disorders was developed.7 The spectrum of autistic conditions is wide ranging. It varies from profound disability in some through to subtle problems of understanding in others of apparently average or above average intelligence. The autistic spectrum includes a number of other conditions that may or may not be separate syndromes, notably Asperger's syndrome. A diagnosis of Asperger's syndrome tends to include individuals at the higher functioning end of the autistic spectrum.

Wing,8 whose work is still relevant today, described individuals with autism as having a triad of impairments:

Absence or impairment of two-way social interaction.

Absence or impairment of comprehension and the use of language and non-verbal communication.

As yet, there is no medication that can ‘cure’ autism, nor are there any medications approved for use in the direct treatment of autism. Medication is usually used to treat a particular symptom or group of related symptoms that are not specific to autism, such as hyperactivity, aggression and self-injurious behaviours.5

Manipulative care

Many chiropractors and other manipulative therapists purport to treat autism and related disorders and report good improvements. However, there are only a handful of published papers regarding the efficacy or mechanism by which manipulative care can help.

Most of the available literature is in the form of anecdotal case reports rather than larger, more meaningful studies. Barnes6 is typical with his claims that, under certain circumstances, children with autism may receive clinical benefit or palliative relief of concurrent problems via chiropractic intervention. Manipulation may, therefore, help with some of the associated symptoms, rather than cure or treat the underlying disease process. Despite these limited claims for success for some children, it may be the associated symptoms that are the most distressing, and preventing them from leading a more normal life.15

Aguilar et al.25 carried out a series of chiropractic adjustments on 26 autistic children over a 9-month period. Twelve were found to have a left atlas laterality and 14 had a right atlas laterality. Outcomes from the study were varied but included normalization of deep tendon reflexes and dermatomal subjective sensation, increased cervical range of motion and reduction of other health problems. Many of the children were taken off Ritalin, bladder and bowel control improved, some children started to speak and eye contact and attention span also improved in some children. Hyperactivity and aggressive behaviour were reduced in other children and five children were able to attend mainstream classes at school for the first time. Behavioural data, recorded by the teachers and parents, showed significant improvements in most cases.

The authors of the study believed that the children were suffering from neurological interference contributing to their diagnosis of autism. This neurological interference was thought to have hindered the development of the child, interfering with their ability to reach their full potential. Aguilar et al.25 believed that correcting a chiropractic subluxation improves local neurological function, allowing for more neurological integration, enabling an overall improvement in function.

Grostic26 supported this view, stating that “abnormal movement of a cervical vertebra is capable of transmitting pathologic forces to the spinal cord and brainstem”. Grostic26 proposed that a misalignment of the first cervical vertebra (atlas) could produce neurological insult directly via mechanical irritation of the spinal cord, and indirectly via vascular compromise of the cervical cord.

Whilst the Aguilar et al. study25 may be one of the most comprehensive yet performed, it still has significant methodological weaknesses. There was no control group and the authors themselves concede that the subjective results could be due in part or in full to natural maturation. However, the observations of these children are encouraging and Aguilar et al.25 suggested that follow up studies of the link between upper cervical adjusting, the nervous system and behaviours are warranted.

Barnes6 has worked with many autistic children and has developed a list of guidelines for manipulative therapists to help maximise the benefits of the treatment (Table 3).

• Establish consistent treatment routines. Since many of these children are disturbed by change, it is best to maintain a general consistency in the way each child is greeted, treated and sent home from visit to visit.

• Avoid any loud disturbances during treatment. Hypersensitivity to a sound is a common problem and may even interfere with therapy. A relaxed quiet environment will promote effective care.

• Distraction is key. Having an assistant distract the child with finger puppets or story books for instance, may allow the clinician to work more effectively.

• Be alert for non-verbal cues of discomfort from the child; these may be areas in need of attention.

• Question parents about changes in behaviour patterns. Significant changes for a child with autism may include the cessation of curious behaviours such as headstands, spinning objects and tugging at clothing. Positive change may also be indicated by an increase in the repertoire of foods the child will eat or an improved use of vocabulary.

Case studies, anecdotal reports and uncontrolled trials do not provide proof of the efficacy of chiropractic care for autistic individuals. However, for some patients and parents, the results are significant and may make a positive difference to their quality of life.

Conclusion

Autism is a life-long developmental disability characterised by impairments in social interaction, communication and imagination.

There is still no agreement regarding the causes of autism, in spite of the many years of research. The areas currently under investigation include anatomy and neurology, as well as the neurochemical and genetic aspects of the condition. There are no medications licensed to treat autism; drugs are used to treat symptoms such as aggression and hyperactivity and special educational techniques are used to help autistic individuals to realise their potential.

Many chiropractors and other manipulative therapists report symptomatic improvements in behaviour following treatment, particularly upper cervical adjusting. However, whilst case studies and anecdotal reports are encouraging, further research in the form of larger, controlled trials are needed to establish the role of manipulative care in the treatment of autism.